Direct Vision, Transfascial (DVT) Approach to Submuscular Reservoir Placement in Patients Undergoing Multicomponent Penile Implant Surgery Following Prior Pelvic Surgery or Radiation Therapy.

BACKGROUND: Submuscular reservoir placement has fulfilled a critical need for patients desiring multicomponent penile implants following pelvic surgery and radiation therapy. Passage of the reservoir through the inguinal canal into the submuscular space is often challenging and carries the risk of the reservoir being placed unknowingly outside of the targeted space. AIM: To evaluate the safety and accuracy of a direct vision, transfascial (DVT) approach to submuscular reservoir placement. METHODS: We retrospectively reviewed outcomes for consecutive patients undergoing DVT submuscular reservoir placement abstracted from a large IRB-approved database at our institution. Postimplant cross-sectional imaging performed on many of these patients was used to ascertain the final location of the reservoir. OUTCOMES: Outcome measures included the perioperative and intermediate-term safety and complications of the procedure. Postimplant imaging ascertained the accuracy in providing patients with a submuscular reservoir. RESULTS: There were 107 DVT submuscular reservoirs placed in 100 consecutive patients. No intraoperative complications occurred, there were no postoperative rectus hematomas, and there were 4 (3.7%) postoperative infections. With a mean follow up of 17.5 +/- 20.5 months there was one reservoir herniation, one patient had autoinflation, and one patient required repositioning of a high riding pump. There were 4 mechanical malfunctions requiring revision at a median of 74 months (range: 69-108 months.) following implant placement. Of the 43 patients who underwent imaging: 34 (79%) reservoirs were accurately positioned, 5 (12%) were in the lateral abdominal wall, 1(2%) was in the retroperitoneum, and 3 (7%) were intraperitoneal. Intraperitoneal reservoirs occurred exclusively in postcystectomy patients. CLINICAL IMPLICATIONS: The DVT approach is technically safe, although a slightly higher than expected infection risk was noted. It provides accurate reservoir placement for the majority of imaged patients. Postcystectomy patients have a risk of insidious intraperitoneal reservoir placement. Preoperative counseling should mention this and postimplant imaging may be considered for some of these patients. Imaging may also helpful prior to future revision surgery in order to identify and remove insidious intraperitoneal reservoirs. STRENGTHS AND LIMITATIONS: We investigated 100 patients, almost half underwent cross sectional imaging. Weaknesses include the retrospective nature of this single-institutional study, which may not have similar outcomes at other centers. CONCLUSION: DVT submuscular reservoir placement is safe following pelvic surgery and radiation therapy. Despite careful and deliberate surgical technique imaging found that approximately 20% of reservoirs are not in their expected location. Intraperitoneal reservoirs are of concern, particularly in postcystectomy patients. Kava BR, Levine A, Hauser N, et al. Direct Vision, Transfascial (DVT) Approach to Submuscular Reservoir Placement in Patients Undergoing Multicomponent Penile Implant Surgery Following Prior Pelvic Surgery or Radiation Therapy. J Sex Med 2022;19:394-400.

Penile injection of aedile silicone: A dangerous shortcut.

INTRODUCTION: The size of penis can cause concern in patients, even if the organ is clinically normal. Additionally, the cost of phosphodiesterase 5 inhibitors (iPDE5) and long waiting lists to access penile prosthesis placement can lead patients to resort to non-medical and potentially dangerous alternatives. One of these dangerous alternatives is the injection of building silicone at the level of the subcutis of the penis or the corpora cavernosa causing the formation of a granuloma that increases the girth and consistency of the penis. CASE REPORT: The article describes the case of a 43-year-old patient who self-injected aedile silicone at the level of his penis in an attempt to achieve greater penile size and greater rigidity. The patient reported that he could not economically afford the iPDE5.The persistence of severe pain in the penis forced the patient to go to a urological examination. The patient subsequently underwent the penile granuloma exeresis procedure and skin reconstruction with scrotal flap. CONCLUSION: The pursuit of sexual well-being can lead some patients to rely on unconventional and potentially harmful techniques. The role of the andrologist and of the scientific society should be to dissuade the patient from using these dangerous methods and to provide valid alternatives accessible to the patient. The economic difficulty in purchasing drugs that facilitate erection or the long waiting lists for the placement of penile prostheses can favor dangerous methods such as penile injection of silicon. There is therefore a clear need to facilitate access to drugs and surgical techniques that favor the patient's sexual well-being.

Effect of operative local anesthesia on postoperative pain outcomes of inflatable penile prosthesis: prospective comparison of two medications.

Few studies have examined the roles of dorsal penile nerve block (DPNB) and penile ring block (PRB) in surgery of inflatable penile prosthesis (IPP) placement. We sought to compare the postoperative pain outcomes of two different medications used in DPNB plus PRB. We thus carried out a prospective study of patients with erectile dysfunction who underwent "de novo" IPP placement between January 2013 and June 2013. Patients were divided to one of three groups: 1-DPNB plus PRB with bupivacaine injection; 2-DPNB plus PRB with ropivacaine injection and, 3-Control group without DPNB or PRB injection. Postoperative pain score and pain medication usage were recorded 2 h postoperatively, and every 24 h, for a week. The Visual Analog Scale (VAS) was used as pain scale measurement. A total of 131 patients were included in this study: 40 to bupivacaine, 47 to ropivacaine, and the rest were controls. Two hours postoperatively, mean VAS was significantly different (p < 0.0001) between medicated patients and the control group, however, no significant differences were observed between medication groups. Mean VAS was not significantly different among the groups from post-surgical day 2 thru 7. In conclusion, DPNB plus PRB during IPP provided effective analgesia in the immediate post-operative recovery.

Silicone implants and lymphoma: The role of inflammation.

The risk of hematological malignancies is mainly determined by genetic background, age, sex, race and ethnicity, geographic location, exposure to certain chemicals and radiation; along with the more recently proposed immune factors such as chronic inflammation, immunodeficiencies, autoimmunity, and infections. Paradigmatic examples include the development of lymphoma in Sjögren's syndrome and Hashimoto thyroiditis, gastric MALT lymphoma in Helicobacter pylori infection, or lymphomas associated with infections by Epstein-Barr virus, human herpes virus 8 (HHV 8) and leukemia/lymphoma virus 1 (HTLV-1). A growing number of reports indicates an increased risk of lymphoma, particularly of the anaplastic large cell (ALCL) type. The implants, specifically those used in the past, elicit chronic stimulation of the immune system against the prosthetic material. This is particularly the case in genetically susceptible hosts. We suggest that polyclonal activation may result in monoclonality in those at risk hosts, ultimately leading to lymphoma. We suggest that patients with an inflammatory response against silicone implants be monitored carefully.

Management of sexual dysfunction due to central nervous system disorders: a systematic review.

OBJECTIVE: To systematically review the management of sexual dysfunction due to central nervous system (CNS) disorders. PATIENTS AND METHODS: The review was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were identified independently by two reviewers using electronic searches of MEDLINE and OVID (from January 2004 to August 2014) and hand searches of reference lists and review articles. RESULTS: In patients with CNS disorders, neuro-urological assessment is recommended for both genders before starting any treatment for sexual dysfunction. For men, blood sexual hormones evaluation is the main investigation performed before phosphodiesterase type 5 inhibitors (PDE5Is) treatment, whereas there is no consensus on routine laboratory tests for women. PDE5Is are the first-line medical treatment for men, with the most robust data derived from patients with spinal cord injury assessed by validated questionnaires, mainly the International Index of Erectile Function-15. There is no effective medical treatment for sexual dysfunction in women. Sacral neuromodulation for lower urinary tract dysfunction may improve sexual dysfunction in both genders. CONCLUSIONS: Although sexual dysfunction is a major burden for patients with CNS disorders, high-evidence level studies are rare and only available for PDE5Is treating erectile dysfunction. Well-designed prospective studies are urgently needed for both genders.

Historical approach to the surgical treatment of erectile dysfunction.

INTRODUCTION: Throughout human history, erectile dysfunction has represented one of the most omnipresent health problems. This has resulted in a search for solutions that, one after the other, have been shown to be fruitless. In this context, the emergence of possible surgical solutions at the start of the 20th century represented a revolution that, even then, would take several decades to demonstrate their effectiveness. ACQUISITION OF EVIDENCE: We performed a literature review that shows the process in the development of potential surgical treatments for hormonal restoration for erectile dysfunction, followed by the sudden emergence of vascular surgery, with new anastomosis techniques, and in the future, the development of penile prosthetic implants as alternative treatments. SUMMARY OF THE EVIDENCE: The publication of results from erectile dysfunction surgery has been lagging for decades due to a lack of objectivity, given that sexual function is a topic restricted by patients' privacy. This situation has led to a reliance on results reported by various authors whose actual credibility could not be verified, with subsequent demonstrations showing that some of these results were not reproducible. CONCLUSIONS: This article reviews some of the most important milestones in the progress of surgeries designed to treat erectile dysfunction. The achievements and apparent failures provide a reason for reflection on how we far we have come and how far we can go in the near future.

A preliminary report on the usage of an intracorporal antibiotic cast with synthetic high purity CaSO4 for the treatment of infected penile implant.

INTRODUCTION: Currently, the surgical treatment of infected penile prostheses is complete removal and either immediate salvage procedure, which carries a significant infection risk, or delayed implantation. With delayed implantation the risk of infection is lower, but the patient loses penile length and width due to corporal fibrosis. AIM: We present our experience with the use of a novel temporary synthetic high purity calcium sulfate (SHPCaSO4) component that acts as a "spacer" at the time of removal of an infected prosthesis while providing constant delivery of local antibiotic elution to the infected area. MAIN OUTCOME MEASURES: Demonstrate that the use of a novel material, SHPCaSO4, can be an innovative way to bridge the gap between removal of an infected penile implant and delayed reimplantation. METHODS: Two patients (Patient A and B) presented with pain and erythema and were found to have infected malleable penile prosthesis. Both underwent removal of all infected components, and sent for tissue culture. The SHPCaSO4 was mixed with vancomycin and tobramycin, allowed to set up for 5 minutes, and then injected into the corporal space followed by closure with 2-0 Vicryl sutures. The injected SHPCaSO4 was palpable in the penile shaft both proximally and distally, as an "intracorporal casts." RESULTS: Patients denied pain postoperatively. Delayed implantation occurred at 6 weeks for patient A. This went uneventful and a new three-piece inflatable implant was inserted. Patient B underwent salvage placement of right malleable implant at 15 weeks, and here significant corporal fibrosis was encountered. Patients have had no infection since their delayed implantation (mean follow-up 4 months). CONCLUSIONS: Data in reference to SHPCaSO4 shows that this product dissolves in approximately 4-6 weeks. This may account for the difference in the ease of delayed implantation between the two patients. Further investigation is warranted.

Vacuum erection devices revisited: its emerging role in the treatment of erectile dysfunction and early penile rehabilitation following prostate cancer therapy.

INTRODUCTION: Vacuum erection devices (VEDs) are becoming first-line therapies for the treatment of erectile dysfunction and preservation (rehabilitation) of erectile function following treatment for prostate cancer. Currently, there is limited efficacy of the use of phosphodiesterase type 5 inhibitors in elderly patients, or patients with moderate to severe diabetes, hypertension, and coronary artery disease. AIM: The article aims to study the role of VED in patients following prostate cancer therapy. RESULTS: Alternative therapies such as VED have emerged as one of the primary options for patients refractory to oral therapy. VED has also been successfully used in combination treatment with oral therapy and penile injections. More recently, there has been interest in the use of VED in early intervention protocols to encourage corporeal rehabilitation and prevention of postradical prostatectomy veno-occlusive dysfunction. This is evident by the preservation of penile length and girth that is seen with early use of the VED following radical prostatectomy. There are ongoing studies to help preserve penile length and girth with early use of VED following prostate brachytherapy and external beam radiation for prostate cancer. Recently, there has also been interest in the use of VED to help maintain penile length following surgical correction of Peyronie's disease and to increase penile size prior to implantation of the penile prosthesis. CONCLUSION: VEDs can be one of the options for penile rehabilitation after prostate cancer therapy.

In vitro assessment of antimicrobial properties of rifampin-coated Titan(®) Coloplast penile implants and comparison with Inhibizone(®).

INTRODUCTION: It is a common practice to soak Titan(®) Coloplast penile implants in antibiotic solution prior to implantation. Aim. The aim of this study is to identify an ideal solution for soaking the Titan(®) Coloplast penile implants prior to implantation. METHODS: Titan(®) strips were soaked in a different combination of antibiotics and the zone of inhibition was studied against Staphylococcus epidermidis and Escherichia coli. This zone of inhibition was compared against zone of inhibition produced by Inhibizone(®) -coated silicone strips. Zones of inhibitions were also compared for different components of Inhibizone(®) implant such as cylinder, tubing, connector, rear tip extender, and reservoir, and compared with similar components of Titan(®) Coloplast penile implants. MAIN OUTCOME MEASURES: The zone of inhibition against S. epidermidis and E. coli for Titan strips dipped in Rifampin and Gentamicin was compared against other antibiotics. The clinical significance of dipping Titan(®) -coated Coloplast implant in Rifampin and Gentamicin solution was determined. RESULTS: Rifampin 10mg/mL+gentamicin 1mg/mL (R10/G1) and rifampin 1mg/mL+gentamicin 1mg/mL (R1/G1) had excellent coverage against S. epidermidis and E. coli. The zone of inhibition (utilizing the Titan(®) coating) produced by both these solutions exceeds that produced by Inhibizone(®) by 40% to 56% for S. epidermidis and 33% for E. coli. Components of the American Medical System implant (tubing connectors and rear tip extenders) are not coated with antibiotics and had no zone of inhibition. CONCLUSION: Soaking Titan(®) -coated Coloplast implants in R10/G1 solution produces a zone of inhibition greater than that produced by Inhibizone(®) -coated penile implants. The clinical significance of this increased zone of inhibition can only be determined by a separate clinical study.

Evolución clínica en los pacientes con implante de prótesis peneana / Clinical evolution in patients with penile prosthesis implant

OBJETIVOS: 1) Evaluar la satisfacción y evolución clínica de los pacientes con prótesis peneana, como tratamiento de la disfunción eréctil biogénica severa. 2) Identificar las complicaciones más frecuentes asociadas a la intervención quirúrgica. 3) Comparar el comportamiento de la satisfacción sexual de los pacientes con implante de prótesis peneana y su pareja, antes y después de aplicado el tratamiento.MÉTODO: Se realizó un estudio descriptivo longitudinal con metodología cuantitativa y cualitativa donde se evaluaron a 25 hombres a los cuales se les había insertado prótesis peneana en el Hospital Faustino Pérez de Matanzas.RESULTADOS: Las complicaciones que se presentaron en nuestra casuística fueron la perforación de la albugínea, el dolor post operatorio, el pene fino y la expulsión de uno o dos cilindros, esta última en un paciente que presentó sepsis peri protésica.CONCLUSIONES: El implante de prótesis peneana constituyó una opción de tratamiento efectiva que logró un 88% de satisfacción sexual en los pacientes implantados. Los pacientes tratados con la implantación de prótesis peneana y sus parejas refirieron incremento en el erotismo, la actividad sexual satisfactoria, mejoría en la auto estima, la comunicación de pareja, el rendimiento laboral, las relaciones personales y sociales y el fortalecimiento del vínculo de la pareja(AU)

OBJECTIVES: 1). To evaluate the satisfaction and clinical outcome in patients with penile prosthesis implant as a treatment to Severe Biogenic Erectile Dysfunction. 2). To identify the most frequent complications associated with the surgical intervention. 3). To compare the behaviour of sexual satisfaction in partners and patients with penile prosthesis implant before and after the application of the treatment.METHODS: A descriptive, (longitudinal) study with quantitative and qualitative methodology was done, where 25 men with penile prosthesis implants, performed at Faustino Perez Hospital, were evaluated.RESULTS: The complications presented in the procedures were perforation of the tunica albuginea, postoperatory pain, thin penis and the expulsion of one or two cylinders, this latter case in a patient who presented periprosthetic sepsis. CONCLUSIONS: The penile prosthetic implant constitutes an option of effective treatment which achieves an 88 % of sexual satisfaction in patients.Both partners and patients treated with penile prosthetic implantation referred increase in erotism, satisfactory sexual activity, improvement of self-esteem, quality of communication with their partner, better labour results, interpersonal and social relationships and strengthening of couple’s bonds(AU)

Restoration of satisfying sex for a castrated cancer patient with complete impotence: a case study.

We present a first-hand account of a fully impotent, testosterone-suppressed prostate cancer patient who has satisfying, multiorgasmic sex using a strap-on dildo. We use his narrative to examine dildos as an alternative to erectile dysfunction treatments for men, such as this patient, who find selective inhibitors of PDE-5 ineffective and surgical intervention unacceptable. We explore what conditions allowed this man to progress from suspicious distrust of the dildo to full acceptance. In terms of making a dildo acceptable to other patients, we contrast offering it to them as a penile prosthesis in a formal medical setting versus treating it as a toy in fantasy sex play. Last, we present a neurobiological hypothesis involving sensory integration to help explain why sex with the strap-on dildo can be satisfying to a male.

Tratamiento de la disfunción eréctil mediante el implante de prótesis de pene. Análisis de nuestra serie / Treatment of erectile dysfunction with penile prothesis. Our experience

INTRODUCCIÓN Y OBJETIVOS: El objetivo de este estudio fue revisar la situación actual de las prótesis de pene en el tratamiento de la disfunción eréctil; así como analizar las indicaciones, el grado de aceptabilidad y las complicaciones en nuestra experiencia. MATERIAL Y MÉTODOS: Entre 1984 y 2003 implantamos 48 prótesis de pene en varones con edad media de 55 años. Los antecedentes patológicos más frecuentes fueron: enfermedad vascular, diabetes mellitus y cirugía pélvica. El tipo de prótesis utilizada fue inactiva maleable en 7 casos (14,58%), Jonas6, Acu-form1. Activa inflable o hidráulica de 3 componentes en 19 casos (39,58%), AMS 700 plus17, Alpha2. Activa inflable, integrada o autocontenida en 5 casos (10,41%), Hydroflex4, Dynaflex1. Activa inflable de 2 piezas en 17 casos (35,4%), Ambicor2, Mark II15. RESULTADOS: El 6,25% presentó infección protésica que obligó a retirar el implante, y el 4,16% complicaciones mecánicas. El 80% de los pacientes se mostraron satisfechos con la prótesis. CONCLUSIONES: Las prótesis peneanas continúan siendo una alternativa válida y eficaz en el tratamiento del varón con disfunción eréctil, presentando un bajo índice de complicaciones

INTRODUCTION AND OBJETIVES: The aim of this study was to review the current situation of penile prosthesis in the treatment of erectile dysfunction and to analyze the indications, degree of acceptability and complications in oir experience. MATERIAL AND METHODS: From 1984 to 2003, 48 implants were inserted in men suffering from impotence due to different etiologies. The mean age was 55 years. Vascular disease, Diabetes and pelvic surgery were the most common pathologies recorded. The type of prothesis inserted were malleable inactive in 7 cases (14.58%), Jonas6, Acu-form1. Inflable active with 3 components in 19 cases (39.58%), AMS 700 plus17, Alpha2. Inflable active integrated in 5 cases (10.41%) Hydroflex4, Dynaflex1. Inflable active with 2 components in 17 cases (35.4%), Ambicor2, Mark II15. RESULTS: Infection of the prosthesis was observed in 6.25% of the cases. This infectious complication required removal of the prosthesis. 4.16% of the cases complained of mechanical failure that required change of the prosthesis. 80% of the patients were satisfied with the results. CONCLUSIONS: Penile prostheses continue to be an effective and valid therapeutic alternative in impotent. Although the complication rate is low, adequate information must be provided to the patient

Outpatient penile implantation with the patient under a novel method of crural block.

Although local anaesthesia for penile implants has been substantially reported, its methodology, simplicity and reliability left room for improvement. We would like to report on an innovative penile crural block using local anaesthesia in patients who underwent penile implantation as outpatient surgery. From March 1987 to March 1991, a total of 21 organically impotent men, aged from 27 to 77 years, received penile prosthesis implantation. All these were performed under pudendal nerve block as an outpatient procedure. From August 1992 to January 2003 a proximal dorsal nerve block with peripenile infiltration and penile crural block was developed to replace the anaesthesia method of pudendal nerve blocks in 137 consecutive patients (aged from 35 to 83 years) undergoing penile implants. The anaesthetic effects and postoperative results with the crural block were very satisfactory. Common immediate side-effects included puncture of the vessels, subcutaneous ecchymosis, transient palpitations and dilation pain, but there were no significant late complications. In the group of pudendal nerve blockage, 42.9% patients (nine of 21) experienced severe aching pain over the perineum for 1-2 weeks postoperatively, whereas the newly developed method of crural block markedly reduced these adverse effects. This new anaesthetic method proved to be reliable, simple, and safe with fewer complications. It offers the advantages of less morbidity, preservation of patient's privacy, reduced adverse effects of anaesthesia, and a more-rapid return to activity with minimal complications.

The InCare Retracted Penis Pouch: an alternative for incontinent men.

Urinary incontinence in men is a common problem in the community setting and within the acute hospital sectors, as well as for people with learning difficulties or those who have a mental illness. There are many causes of incontinence, some are the result of surgical intervention, as in post-prostatectomy urinary incontinence, bladder dysfunction caused by a congenital abnormality where the ability to develop bladder control is affected, or as a side effect of tranquillizer or other medication. All patients with urinary incontinence episodes should have thorough investigation of this problem as it is often a sign or symptom of an underlying condition, such as an enlarged prostate, urethral stricture, or atomic or naturopathic bladder. Effective bladder voiding function must be established before the assessment for any urinary collection device. Advice on assessment and treatment modalities can be sought from local continence advisers or clinical nurse specialists

Penile prosthesis surgery under local penile block anaesthesia via the infrapubic space.

The aim of this study was to evaluate the effectiveness and patient tolerance to local penile block anaesthesia via the infrapubic space with penile prosthesis implantation. Local anaesthesia was administered using a 23-guage 1.5-inch needle. A 50-50 mixture of 0.5% bupivicaine (Marcaine) and 0.5% lidocaine (Xylocaine) without adrenaline was injected into the infrapubic space with additional subcutaneous penile ring infiltration at the level of the penile root. A total number of 159 patients underwent this technique, mean age 57 years (range 34-86). In 148 (93%) patients, no booster sedation was needed; eight (5%) patients needed a boost of the pre-operative sedative during crural dilatation; three (1.8%) patients required general anaesthesia owing to insufficiently effective local anaesthesia and unexpectedly difficult dilatation. It is concluded that local anaesthesia was effective and safe to produce a pain-free procedure in 93% of cases. However, as the need for booster sedation or general anaesthesia exists, the procedure should be performed under monitored anaesthetic care and pre-operative evaluation should be performed as for general anaesthesia.

Assessment and management of erectile dysfunction in men with diabetes.

PURPOSE: Erectile dysfunction occurs earlier in men with diabetes than in the general population, affecting over 50% of male patients by age 60. This article summarizes the etiologies and presents methods of patient assessment and treatment options for erectile dysfunction. METHODS: Assessments of neurologic and vascular complications related to diabetes should be included in a sexual function history. The assessment must be holistic and focus on organic as well as psychogenic causes. Diabetes educators must be prepared to discuss the various pharmacologic treatment options. RESULTS: Sildenafil currently is the only oral medication available for erectile dysfunction. Injectable treatments have proven successful but with limited long-term use and poor patient acceptance. Implantable devices carry surgical risk and increased rates of infection. CONCLUSIONS: All men with diabetes should be screened for erectile dysfunction. The availability of a new oral medication provides a patient-acceptable treatment option.